Conservative Management of Rectal Prolapse While Awaiting Surgery
Start with dietary modifications, fluid management, bowel training programs, and management of constipation or diarrhea with medications, as approximately 25% of patients will benefit from conservative therapies alone. 1
Immediate Management for Acute Prolapse
If the prolapse is currently protruding and requires reduction:
- Position the patient in Trendelenburg to use gravity to assist reduction, and administer intravenous sedation and analgesia before attempting manual reduction 2
- Apply topical granulated sugar directly to the prolapsed rectal tissue for 10-15 minutes to reduce edema by creating a hyperosmolar environment that draws out water molecules 2
- Alternative edema-reduction methods include hypertonic solutions (50% dextrose or 70% mannitol), submucosal hyaluronidase infiltration, or elastic compression wrapping 2
- After edema reduction, apply steady, gentle circumferential pressure using both hands to compress and guide the tissue back through the anal sphincter, avoiding excessive force 2
Red Flags Requiring Immediate Surgical Intervention
- Signs of shock or hemodynamic instability 2
- Evidence of tissue gangrene or perforation 2
- Strangulation with vascular compromise 2
- Bleeding that cannot be controlled conservatively 2
- Acute bowel obstruction 2
- Failure of manual reduction attempts 2
Conservative Medical Management
Bowel Management
- Dietary modifications and fluid management are first-line conservative measures 1
- Bowel training programs to establish regular defecation patterns 1
- Medications to manage constipation or diarrhea as needed 1
- When biofeedback fails, emphasize suppositories and enemas for symptom control 1
Pelvic Floor Therapy
- Pelvic floor biofeedback therapy is recommended to correct underlying pelvic floor dysfunction 1
- This is particularly important as surgery is necessary in less than 5% of patients with defecatory disorders - the vast majority should be managed conservatively with biofeedback therapy 1
Symptom-Specific Management
For patients experiencing severe tenesmus (persistent urge to defecate):
- Low-dose tricyclic antidepressants can break the vicious circle of straining and deterioration 3
- Nortriptyline 25 mg daily showed 90% response rate 3
- Desipramine 25 mg daily showed 100% response rate 3
- Amitriptyline 10 mg daily showed 62.5% response rate 3
- These medications address rectal hypersensitivity that triggers the straining-prolapse cycle 3
Important Caveats
- Never attempt prolonged conservative management in patients with signs of ischemia, perforation, or hemodynamic compromise 2
- Administer empiric broad-spectrum antibiotics if there are any signs of strangulation due to risk of intestinal bacterial translocation 2
- The correlation between symptom improvement and anatomical correction is often weak, so managing expectations is critical 1
- All patients with external rectal prolapse should ultimately be offered surgical repair, as the natural history frequently leads to complications of incontinence and constipation 4